Varicocelectomy is associated with increases in serum testosterone independent of clinical grade

Trends for Surgical Treatment of Testicular Varicocele: A German Whole-population Analysis of Inpatient Procedures from 2006 to 2021

Background and objective

Testicular varicocele (TVC) is a common benign finding in men of all ages. Indications for TVC repair are abnormal sperm parameters and testicular pain. The optimal surgical method for TVC repair is still a matter of controversy. The aim of our study was to analyze the current situation and trends for TVC surgery in Germany.

Methods

The German reports for hospital quality were analyzed from 2006 to 2021. Linear regression models were applied to detect trends over time. Outpatient procedure rates were estimated.

Key findings and limitations

A total of 38 653 inpatient TVC surgeries were included. Total varicocelectomy procedures decreased from 3456 in 2006 to 2165 in 2021 (-37.4%; p < 0.001). The proportion of open TVC procedures remained constant at ∼25%. The proportion of laparoscopic TVC procedures increased from 25% in 2006 to 45% in 2021 (p < 0.001), while the sclerotherapy rate for TVC treatment decreased from 47% in 2006 to 29% in 2021 (p < 0.001). In 2006, 543 hospitals offered TVC treatment, which decreased to 466 hospitals in 2021 (-14.2%). Among patients undergoing surgical TVC procedures in 2021, 75% were younger than 35 yr. We estimated an increase in outpatient procedures from 365 cases in 2013 to 1330 cases in 2021 (p < 0.001). The estimation for outpatient procedures represents a study limitation.

Conclusions and clinical implications

Laparoscopic TVC treatment is the dominant surgical approach. However, one in three patients receives sclerotherapy for TVC in Germany. While fewer hospitals offer the treatment, we observed a trend for centralization, with an increase in high-caseload departments, as well as an increasing trend for outpatient treatment.

Patient summary

TVC is a collection of swollen veins in the testicle. We analyzed treatment trends in Germany for this condition from 2006 to 2021. There was an increase in the use of keyhole surgery over time, and we estimate that the percentage of day-case surgeries also increased.

Sperm metabolomic profiles of varicocele-associated asthenozoospermia

Varicocele is a leading cause of male infertility, with asthenozoospermia being a common phenotype. The metabolic basis of varicocele-induced asthenozoospermia remains poorly understood, necessitating a comprehensive metabolic profiling study. This GC-MS-based metabolomic study investigated sperm metabolic profiles across three cohorts: healthy controls (HC, n = 30), varicocele patients with normal motility (VC, n = 30), and varicocele-associated asthenozoospermia cases (VA, n = 30). Multivariate analyses (Principal Component Analysis, Partial Least Squares Discriminant Analysis, and Orthogonal Partial Least Squares Discriminant Analysis) of 85 identified endogenous metabolites revealed progressive metabolic dysregulation: 25 differential metabolites (including cysteine, leucine, glycine) distinguished VC from HC, while 29 additional perturbations (valine, threonine, alanine) characterized VA cases. These findings systematically delineate varicocele-related metabolic disturbances, providing mechanistic insights into sperm motility impairment and potential therapeutic targets for male infertility management.

Effects of Varicocele Repair on Testicular Endocrine Function: A Systematic Review and Meta-Analysis

PURPOSE

The objective of this manuscript is to assess the effect of varicocele repair (VR) in patients with clinical varicoceles on serum total testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and inhibin B serum levels.

MATERIALS AND METHODS

The study was performed in compliance with the Meta-Analysis and Systematic Reviews of Observational Studies (MOOSE) guidelines and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). All eligible studies were selected following the PICOS (Population, Intervention, Comparison/Comparator, Outcomes, Study design) model. The values of each outcome measured after VR were compared to the before parameters and, when available, to the values on patients with unrepaired varicocele, and to those of healthy controls with no varicocele. For total testosterone, the values were sub-analyzed based on the mean total testosterone levels before VR (<300 ng/dL or >300 ng/dL), the fertility status, the time of follow-up and the technique used for VR.

RESULTS

From a total of 460 abstracts retrieved, 48 articles were included in our meta-analysis. Serum total testosterone levels were significantly higher after VR compared to both pre-treatment levels (mean difference [MD] 82.45 ng/dL, 95% confidence interval [CI]: 64.14-100.76; p<0.00001) and to the levels of patients with unrepaired varicocele (MD 91.64 ng/dL, 95% CI: 62.30-120.99; p<0.00001). They did not differ from the levels of healthy controls with no varicocele (MD -22.01 ng/dL, 95% CI: -68.59-24.58; p=0.35). The increase resulted to be independent from the mean total testosterone levels before VR, fertility status, time of follow-up and type of VR. After VR, a trend toward lower serum LH levels was found compared to before values (MD -0.37 IU/L, 95% CI: -0.74-0.01; p=0.06). When compared to the levels of patients with unrepaired VR, LH levels after VR were significantly lower (MD -0.96 IU/L, 95% CI: -1.56 to -0.35; p=0.002). LH levels were not significantly higher than healthy men without varicocele (MD 0.84 IU/L, 95% CI: -0.68-2.36; p=0.28). Patients with VR had significantly lower FSH levels compared to their pre-treatment values (MD -1.43 IU/L, 95% CI: -1.82 to -1.04; p<0.00001), and also to those of patients with non-repaired varicocele (MD -2.35 IU/L, 95% CI: -4.06 to -0.65; p=0.007). When compared to healthy controls with no varicocele, FSH levels were significantly higher (MD 2.71 IU/L, 95% CI: 1.12-4.31; p=0.0009). Lastly, after VR no significant change in inhibin B serum levels was seen compared to pre-treatment levels (MD 11.76 pg/mL, 95% CI: -3.83-27.35; p=0.14).

CONCLUSIONS

The present meta-analysis is the largest to date to assess the impact of VR on Leydig cell and Sertoli cell function using a before-after analysis for uncontrolled studies, and using data from patients with unrepaired varicoceles or healthy patients without varicocele as controls. VR was found to increase and restore to normality serum levels of total testosterone and LH. This evidence could be of value in considering the treatment of varicocele in patients with low testosterone or those who show a progressive decline in testosterone levels.

Can serum 17-hydroxy progesterone predict an improvement in semen parameters following micro-varicocelectomy? A prospective study

BACKGROUND & OBJECTIVES

Notably, 17-hydroxy progesterone (17-OHP) (17-OHP) is a precursor for testosterone (T) synthesis, and intratesticular testosterone (ITT) is essential for spermatogenesis. Varicocele (Vx) has an estimated prevalence of 15% in the general population and 35% in those with primary infertility. We aimed to evaluate the correlation between changes of serum 17-OHP after sub-inguinal micro-varicocelectomy and improvement of semen parameters.

PATIENTS AND METHODS

The current prospective study included 45 infertile men attending the andrology clinic form February 2021 to August 2021. Two semen analyses and hormonal profile were evaluated. Colored duplex ultasonography (CDUS) was done in standing and supine position for accurate measurements of testicular volumes and confirmation of Vx. Patients underwent sub-inguinal micro-varicocelectomy using a surgical microscope HB surgitech. We followed them prospectively up for three months following micro-varicocelectomy with serum TT and 17-OHP.

RESULTS

Sperm concentration improved significantly from 8.36 ± 5.04 million/ml to 12.52 ± 8.42 million/ml after 3 months following sub-inguinal micro-varicocelectomy (p= 0.001), with normalization of concentration in 15/45 (33%) patients. Total motility did not improve significantly but progressive motility improved significantly from 8.62 ± 8.74% to 16.24 ± 14.45% (p=0.001). Abnormal forms significantly declined from 96.67 ± 2.03% to 95.75 ± 2.47% (p=0.009).  Serum 17 OHP and 17 OHP/total testosterone (TT) improved significantly from 1.21 ± 0.45 ng/ml and 0.26 ± 0.09 to 1.42 ± 0.76 ng/ml and 0.3 ± 0.16 (p= 0.013, p= 0.004), respectively, while serum TT did not improve significantly. A significant correlation was found between improvement in sperm concentration and both serum 17 OHP and 17 OHP/TT ratio (p=0.001, p=004). Furthermore, change in abnormal sperm forms showed significant correlations with changes in both 17-OHP and 17-OHP/TT.

CONCLUSION

17 OHP and 17OHP/ TT ratio can be used as biomarkers to detect improvement in semen parameters following sub-inguinal micro-varicocelectomy.

Feasibility of loupe assisted subinguinal varicocelectomy in treatment of male infertility

OBJECTIVES

To study the impact of loupe assisted subinguinal varicocelectomy on semen quality, serum testosterone level, and spontaneous pregnancy rate.

METHODS

The data were prospectively collected for 102 infertile men with clinical varicocele. The preoperative values of semen analysis parameters and serum testosterone level were compared with postoperative values at 6 months. Spontaneous pregnancy was assessed at 6 months.

RESULTS

The mean age of patients was 31.56 ± 4.31 years. Primary infertility was reported in 86 patients, while 16 had secondary infertility. Bilateral varicocele was seen in 79 patients while 23 had a unilateral varicocele. The total sperm concentration (×10⁶/mL) before and after varicocelectomy was 12.82 ± 3.91 and 20.06 ± 2.13 respectively (P < .0001). The total sperm motility (%) before and after varicocelectomy was 37.67 ± 7.23 and 55.46 ± 4.51 respectively (P < .0001). The sperm morphology (Kruger/Strict morphology criteria, %) before and after varicocelectomy was 3.11 ± 0.80 and 3.70 ± 0.78 respectively (P < .0001). The serum testosterone level (ng/dL) before and after varicocelectomy was 323.90 ± 67.81 and 396.74 ± 40.88 respectively (P < .0001). The Spontaneous pregnancy rate in couples with primary and secondary infertility was 18.60% and 31.25% respectively. The difference in their rates was not significant (P = .251). The overall spontaneous pregnancy rate was 20.5%.

CONCLUSION

Loupe-assisted sub-inguinal varicocelectomy is a safe and effective modality for treating infertile men, particularly when provision for microscopic surgery is unavailable. However, only large size comparative studies or multi-centric trials can confirm this.

Robotic Surgery for Male Infertility and Chronic Scrotal Content Pain

Robot-assisted microsurgery is a trending approach for the treatment of male infertility and chronic scrotal pain. The advantages seem to include increased optical magnification, improved surgical efficiency, absent tremor, and similar outcomes with standard methods. This chapter covers robotic microsurgical application and techniques for: robot-assisted vasectomy reversal with vasovasostomy and vasoepididymostomy, varicocelectomy, microsurgical testicular sperm extraction, and targeted denervation of the spermatic cord.

Microsurgical Management of Male Infertility: Compelling Evidence That Collaboration with Qualified Male Reproductive Urologists Enhances Assisted Reproductive Technology (ART) Outcomes

A male factor plays a significant role in a couple's reproductive success. Today, advances in reproductive technology, such as intracytoplasmic sperm injection (ICSI), have allowed it to be possible for just a single sperm to fertilize an egg, thus, overcoming many of the traditional barriers to male fertility, such as a low sperm count, impaired motility, and abnormal morphology. Given these advances in reproductive technology, it has been questioned whether a reproductive urologist is needed for the evaluation and treatment of infertile and subfertile men. In this review, we aim to provide compelling evidence that collaboration between reproductive endocrinologists and reproductive urologists is essential for optimizing a couple's fertility outcomes, as well as for improving the health of infertile men and providing cost-effective care.

Bibliometrics and visualisation analysis of literature on varicocele: From 2002 to 2021

Varicocele is a common disease in men, with a global incidence of approximately 25%. A comprehensive and systematic analysis of the knowledge map on it will help in assessing frontier research and identify knowledge gaps. In total, 4103 articles published from 2002 to 2021 in 1066 journals were included. They represent the current research status worldwide, potential hotspots and future research directions. In the past decades, the number of publications and citations of varicocele-related studies have increased steadily. Academic institutions in the United States played a leading role in varicocele research. The country, institution, journal and author with the most publications were the United States (779), Cleveland Clinic Foundation (132), Andrologia (246) and Agarwal A (106), respectively. The most frequently used keywords were Varicocele (1620), Male Infertility (944), Varicocelectomy (288), Testis (245), Sperm (166), Oxidative Stress (144), Azoospermia (119), Semen Analysis (118), Laparoscopy (116) and Adolescent (97). Currently, the main focus of current varicocele research is its surgical treatment method and effect on sperm quality. The frontier research hotspot is the specific mechanism of varicocele-induced decrease in sperm quality.

Retinal vessel diameters: Can they predict future risk of infertility in patients with varicocele?

OBJECTIVE

The objective of this study was to assess the relationship between retinal vessel diameters, such as retinal arteriolar diameter, retinal venular diameter, and arteriolar/venular ratio (AVR), as clinical parameters of fertility in varicocele patients.

MATERIALS AND METHODS

Sixty-eight (68) infertile varicocele men with abnormal semen parameters and sixty-one (61) varicocele normozoospermic men were included in the study. Moreover, fifty-eight (58) healthy normozoospermic men without varicocele were enrolled as a control group. For each participant, retinal vascular diameters were measured from the digital retinal photographs as a central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE), and AVR. In addition, hormones (total testosterone and FSH), and semen parameters were assessed and correlated with retinal vessel diameters.

RESULTS

The mean CRAE, CRVE, and AVR values were 147.8 ± 15.8 μm, 198.3 ± 39.3 μm, and 0.61 ± 0.01 in infertile varicocele patients, respectively. Significant difference of CRAE, CRVE, and AVR were found when comparing infertile varicocele patients with both varicocele and control normozoospermic male groups (p = 0.01, p = 0.006, and p = 0.007; respectively). Larger retinal venular caliber and smaller AVR ratio showed a significant inverse correlation with both sperm parameters and hormones (total testosterone and FSH) (p < 0.05). No significant correlations were found between CRAE with both sperm parameters and hormonal values (total testosterone and FSH) (p > 0.05).

CONCLUSIONS

Infertile patients with varicocele showed a significant relationship with the retinal vascular diameter (CRVE and AVR ratio). This finding supports recommendation for regular eye examinations in the varicocele population.

Relationship between Varicocele and Male Hypogonadism: A Review with Meta-Analysis

The relationship between varicocele and hypogonadism becomes clearer everyday thanks to the most recent literature, particularly with regards to the impact of varicocele repair on serum testosterone level improvement in hypogonadal patients. We selected English articles published from 1964 to September 2021. The search terms “varicocele” and “hypogonadism” were used as filters. A total of 102 studies have been obtained. For the meta-analysis, the pooled mean differences (MDs) for continuous variables and the ln(OR) were used for data pooling observational studies. A total of 15 articles have been finally included: nine retrospective and six observational. Testosterone levels pre- and after surgery were reported in four studies. There was statistically significant heterogeneity in these studies (chi2 = 267.09, I2 = 72%; p = 0.01). Mean differences of total testosterone was statistically different in men pre- and after-surgery (mean difference = 106.76; p < 0.0001). It is indeed established that altered environments caused by varicocele cause pantesticular insult, but it has not been unequivocally determined whether men with varicocele are at increased risk for the development of clinical hypogonadal symptoms.

Oxidative Stress: A Comprehensive Review of Biochemical, Molecular, and Genetic Aspects in the Pathogenesis and Management of Varicocele

Oxidative stress is a condition due to an imbalance between the concentrations of oxidants and antioxidants, and it is a well-recognized contributor in several male infertility conditions. Varicocele, a common vascular condition, may cause male infertility due to hyperthermia, hypoxia and/or exposure to toxic adrenal and renal metabolites. In this review, the mechanisms by which oxidative stress can affect cellular integrity and functions are described, along with molecular markers of cellular oxidative damage, and the most commonly performed techniques for their detection in seminal fluid. Moreover, we focus on the role of oxidative stress in the pathophysiology of varicocele based on recently published evidence from omics based studies, such as proteomics and genomics. Finally, we discuss strategies for the management of oxidative stress and the clinical guidelines for testing oxidative stress-related sperm DNA fragmentation in this group of patients.

Is there a relationship between varicocele and testosterone levels?

OBJECTIVES

The goal of this work was to study the relationship between presence of varicocele and testosterone serum levels in adulthood.

METHODS

A comparative, cross-sectional study of 387 men who consulted for erectile dysfunction. Age, body mass index (BMI), diabetes (DM), and presence of varicocele were related to testosterone levels through uni- and multi-variate analysis.

RESULTS

A total of 248 cases (70.8%) had no varicocele, 46 (13.1%) had grade I varicocele, 36 (10.3%) grade II, and 20 (5.7%) grade III. The mean total testosterone levels were 4.77 ng/mL in the non-varicocele group and 4.34 ng/mL in the varicocele group (p = .91), while free testosterone levels were 69.81 and 73.24 pg/mL (p = .18), respectively. In the multivariate analysis, BMI> = 30 was related to low total testosterone levels (OR: 2.94, p < .001) and low free testosterone (OR: 2.01, p = .01), while advanced age associated with low levels of free testosterone (OR: 1.04, p < .001).

CONCLUSIONS

We were not able to establish a relationship between the presence of varicocele and decreased serum testosterone levels. Other factors already described, such as obesity and age, were related to low levels of total and free testosterone.

Effect of microsurgical varicocele repair on sexual functions and testosterone in hypogonadal infertile men with varicocele

OBJECTIVE

To investigate effect of microsurgical varicocele repair on sexual functions and serum total testosterone level in infertile hypogonadal men with varicocele, and also to determine factors that might predict improvement in total testosterone level after surgery.

METHODS

The study included 202 infertile hypogonadal men (total testosterone level of <3.5 ng/mL) with varicocele who underwent microsurgical sub-inguinal varicocele repair.

RESULTS

Mean serum total testosterone level significantly increased from 2.55 ± 0.66 ng/mL to 3.72 ± 1.34 ng/mL after varicocelectomy (p = .000), and 105 patients (52%) had serum total testosterone level of ≥3.5 ng/mL after the surgery. Mean international index of erectile functions (IIEF-EF) score significantly increased from 27.47 ± 2.96 to 28.61 ± 2.02, post-operatively (p = .000). Of the patients who had pre-operative IIEF-EF score of ≤26, 65.5% had IIEF-EF score of ≥26 after varicocelectomy. Of the patients who had pre-operative decreased libido, 86.6% had post-operative increased libido. Only older patient age was the predictor for having total testosterone level of ≥3.5 ng/mL after the surgery (p = .031).

CONCLUSIONS

Data suggest that serum total testosterone level, IIEF-EF score and sexual libido significantly increase after varicocele surgery. As the age increases, total testosterone level increased after varicocele surgery. Therefore, varicocele repair could be offered to hypogonadal men with clinically varicocele.

Comparison of the result of Doppler sonography before and after laparoscopic artery and lymphatic sparing varicocelectomy with microsurgical subinguinal varicocelectomy

Background:

Based on the importance of varicocele, the aim of this is to compare the comparison between doppler sonography before and after laparoscopic lymphatic sparing varicocelectomy and microsurgical subinguinal varicocelectomy.

Patients and Methods:

Patients with primary varicocele who were referred to Ahwaz Imam Khomeini Hospital after informed consent were included. Primary information included varicocele severity, pain intensity, latency, Doppler sonography (Resistive index (RI), venous return, venous diameter before and after Valsalva) were obtained, and then patients were entered into one of the two groups of surgery. The admission duration, return to work duration, the pain and analgesic consumption, and the length of anxiety were recorded in patients. Patients were examined 3 months later, and the severity of varicocele in the examination, pain score, latency, Doppler sonography indices, sperm indices in both groups were registered. In the end, the information is entered into Statistical Package for the Social Sciences (SPSS) statistical software and evaluated.

Results:

We observed that the severity of varicocele (P = 0.34), pain (P = 0.45), latralite (P = 0.56), RI (P = 0.65), intravenous diameter (P = 0.75) did not show statistically significant difference between the two groups, also in evaluating these indices after surgery, there were significant differences between the two groups in pain (P = 0.04) and time for return to work (P = 0.036).

Conclusions:

The methods used in varicocelectomy did not have any effect on the outcome of the treatment. Accordingly, using any of these methods can improve the post-surgical state of the patients and promote the fertility performance and reduction of complications due to surgery in patients.

Effect of microsurgical varicocelectomy on semen parameters, serum, and intratesticular testosterone levels

Objective

The goal of this work was to evaluate if men who underwent microsurgical varicocelectomy would have improvement in serum testosterone (T) as well as serum 17-hydroxyprogesterone (17-OHP-An intratesticular T biomarker) in addition to semen parameters after operation.

Materials and Methods

We conducted a prospective analysis of 30 men who underwent microsurgical varicocelectomy from December 2018 to September 2019. We assessed varicocele grade and laterality, serum T, serum 17-OHP, serum follicle- stimulating hormone (FSH), serum LH, and semen parameters in baseline and follow-up. According to the data distribution, we reported the median and interquartile ranges and utilized the Mann-Whitney U, Student's t test and Wilcoxon rank test. Correlation analysis was performed with the Spearman test.

Results

In the baseline, 9 (30%) men had 17-OHP < 55 ng/dL and 21 (70%) men presented with 17-OHP > 55 ng/dL. Also, 19 men had TMSC < 9 million, including 6 men with azoospermia, 1 man with cryptozoospermia, and 11 men with TMSC > 9 million. We found an improvement in most SA parameters of most men, which include concentration (63.3%, 19/30), motility (46.6%, 14/30), and TMSC (60%, 18/30). About seven (36.8%) men had TMSC upgraded to > 9. There was a significant change in volume (2.1 [1.5-2.8] to 2.4 [1.7-3.6] cc, P = .018), concentration (6.8 [0.8-22.5] to 12.5 [1-31] million/cc, P = .047) and TMSC (4.4 [0.3-15.1] to 10.5 [0-41.8] million, P = .012) after surgery. We neither found a change in serum T nor a change in intratesticular T (serum 17-OHP) after varicocelectomy (P > .05). FSH, LH and T were similar both before and after varicocelectomy (P > .05).

Conclusion

Despite improvement in semen parameters following varicocelectomy, we did not see changes in either serum or intratesticular T. This suggests that improvement of semen parameters following varicocele repair could be from factors other than changes in androgen levels within the testis.

Effect of Varicocele and Its Treatment on Testosterone in Hypogonadal Men with Varicocele: Review of the Literature

Varicocele might cause deterioration in Leydig cell functions, and it is a significant risk factor for hypogonadism. Some controversial issues have been raised in the treatment of hypogonadal men with varicoceles. Symptomatic hypogonadal men with varicoceles have two options: testosterone replacement therapy or varicocele treatment. Both approaches have some advantages and disadvantages. This review summarizes the effect of varicoceles on total plasma testosterone level and addresses whether varicocele repair is effective to improve testosterone levels in hypogonadal men with varicoceles. Experience from large clinical studies in the literature suggests that varicocele repair may increase serum testosterone level in men with varicoceles and testosterone deficiency. Varicocele repair could be offered to men with clinically palpable varicocele and hypogonadism. As the treatment method, microsurgical varicocele repair could be preferred to provide the best improvement. Another advantage of varicocele repair for hypogonadism, instead of exogenous testosterone treatment, is its ability to preserve the fertility status in men who may desire a child in the future. However, further studies are required to clarify varicocel-related Leydig cell dysfunction and to advise hypogonadal patients about the sufficient effectiveness of varicocele repair.

Pathophysiology and treatment options of varicocele: An overview

Varicocele is the most common correctable cause for male infertility, but not all men with varicocele are affected equally by this condition. The pathophysiology of varicocele-induced fertility remains ill-defined. While evidence suggests that oxidative stress remains a central factor, other mechanisms likely include scrotal hyperthermia, reflux of metabolites, hypoxia and cadmium accumulation. Microsurgical varicocelectomy remains the gold standard treatment option for infertile men with a clinically palpable varicocele and abnormal semen parameters. Newer evidence suggests a potential role for antioxidant supplementation and a meaningful role of varicocelectomy for patients destined for ART to improve pregnancy outcomes.

Long-term NaHS administration reduces oxidative stress and apoptosis in a rat model of left-side varicocele

The main aim of this study was to assay the testicular H2 S levels in the varicocele rat model and then to investigate the protective effects of NaHS on morphometric changes, sperm parameters, oxidative stress and apoptosis markers in rat's testis. D,L-propargylglycine (PAG) was administrated to show the effects of cystathionine γ-lyase enzyme (CSE) inhibition in the varicocele. Rats were assigned to four groups: (a) Sham, (b) varicocele, (c) varicocele + PAG and (d) varicocele + NaHS. Animals in varicocele + NaHS group received 30 µmol/L NaHS in drinking water for 56 days. In the varicocele + PAG group, animals received PAG 19 mg/kg twice a week. Morphometric assessment, oxidative stress markers, testicular H2 S levels, sperm parameters, TUNEL assay and expression of Bax/Bcl2 were evaluated at the end of experiment. Testicular H2 S levels were significantly decreased in varicocele group. NaHS significantly improved sperm parameters, morphometric characteristics and oxidative stress compared to varicocele group. Oxidative stress status deteriorated in the PAG group compared to the varicocele group. This study showed that a low testicular H2 S level might play a critical role in male infertility. Thus, NaHS administration may be a promising treatment strategy for male infertility in varicocele. In addition, CSE may not be the only important enzyme in testicular H2 S production.

The prevalence and severity of varicocele in adult population over the age of forty years old: a cross-sectional study

Objectives: To investigate the prevalence and severity of varicocele in adult population over the age of 40. We also measured testicular size, consistency, and total testosterone levels with an aim to observe the effect of varicocele on testis as men age. Methods: Two hundred twenty-four patients with varicocele, 241 patients without varicocele who admitted to our clinic were enrolled in the study. We stratified participants by four age groups (40-49, 50-59, 60-69, >70 yr). Patients were grouped according to varicocele grade and laterality. The morning testosterone level was drawn. The subgroups were compared with each other. Results: Overall, varicocele prevalence was 48%. Of the patients, 104 had unilateral, 120 had bilateral varicocele. Of the patients with varicocele, 62 (13.30%) were found as grade 3, 99 (21.10%) were grade 2, and 63 (13.60%) were grade 1. The percentages of smaller testes in grade 1, grade 2, and grade 3 varicocele group were 20.60, 79.80, and 88.70 and a significant association was detected. Age stratification of the data revealed the smaller and soft testis prevalence as well as higher grade varicocele prevalance increased in older age groups. Conclusions: Varicocele presence is associated with lower testicular size, softer testicular consistency, and lower testosterone levels, especially in older patients with bilateral and high-grade varicocele.

Indications and outcomes of varicocele repair

Varicoceles exert deleterious effect on testicular function. The condition has been associated with male infertility, testicular hypotrophy and pain. These comprises the common indications for varicocele repair currently. Significant improvement in semen parameters and pregnancy outcomes had been suggested by reports decades ago. However, selection of the best candidates remains an issue since not all patients respond positively to treatment. Consensus has been reached in recent decade after the publication of a series of meta-analyses. Significant improvement in pregnancy outcomes were reported in patients with clinical varicocele and abnormal semen parameters. Varicocelectomy in adolescents with testicular hypotrophy was supported by the positive implication on catch-up growth and semen parameters. However, little is known about the treatment effect of adolescence varicocelectomy on long term fertility and paternity rate. Recent studies on outcome of varicocele repair for pain consistently demonstrated a resolution rate of approximately 90% and support varicocele-associated pain as an indication for surgery. Alternate indications for varicocele repair have been proposed in recent decade. Despite the encouraging preliminary data, most studies were uncontrolled retrospective series. Although varicocelectomy may not obviate the need for assisted reproductive techniques in patients with non-obstructive azoospermia, it potentially increases sperm retrieval rate. The significant increase in serum testosterone after varicocelectomy in patients with androgen deficiency may open an alternative treatment for hypogonadism. The adjunctive role of varicocelectomy before assisted reproduction and the significant decrease in sperm DNA fragmentation after varicocele repair deserve further well-designed controlled studies.

Hypogonadism is independently associated with varicocele repair in a contemporary cohort of men in the USA

We aimed to identify demographic and clinical predictors of varicocele repair in a contemporary cohort of men in the USA. We queried the 2009-2015 MarketScan Database using relevant ICD9, ICD10, and CPT codes to identify all 18-45 year olds with varicoceles. Differences in age, area of residence, clinical characteristics, and medical management between men who did and did not undergo varicocelectomy (open, laparoscopic, or microsurgical) during the study period were compared using unpaired t -tests and Chi-squared tests for continuous and categorical variables, respectively. Multivariable logistic regression analysis was used to evaluate age, semen analyses, and serum hormone assessment as predictors of varicocele repair. SAS version 9.4 was used for all statistical analyses. Significance was set at P < 0.05. Approximately 40% of men with varicoceles underwent repair, primarily through an open approach. Men who underwent repair were more likely to have a diagnosis of male infertility (15.5% vs 7.9%, P < 0.001) and male hypogonadism (3.4% vs 0.9%) and were more likely to complete semen analyses (36.1% vs 12.2%, P < 0.001) and serum testosterone evaluation (42.5% vs 18.8%, P < 0.001). In multivariable regression models, the strongest predictors of varicocele repair were semen analysis (OR = 2.78, 95% CI: 2.56-3.02), age 18-25 years (OR = 2.66, 95% CI: 2.36-2.98), and serum testosterone evaluation (OR = 1.67, 95% CI: 1.51-1.86). Although male infertility remains the most important indication for varicocele repair, male hypogonadism is emerging as an independent predictor of varicocelectomy, which may represent a change in the clinical management of varicoceles in the USA.

A preliminary evaluation of serum level of testosterone, LH, and FSH in patients with varicocele after varicocelectomy as a kidney-related disease

Introduction

Varicocele is a common problem with a high prevalence in population with primary and secondary infertilities. The adverse effects of varicocele on spermatogenesis and fertility are known, but the association between clinical varicocele and testosterone is not clear. Hence, we decided to evaluate the serum levels of testosterone, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in patients with varicocele after varicocelectomy.

Methods

In this study, 100 patients with varicocele were divided into two groups: hypogonadal patients with testosterone level <280 ng/dL and eugonadal patients with testosterone level >280 ng/dL. The serum levels of testosterone, FSH, and LH were measured before surgery and 3 months after surgery, and the results were analyzed using the SPSS software. P-value <0.05 was considered statistically significant.

Results

Patients with varicocele after puberty till 50 years were divided into two groups: hypogonadal (testosterone <280 ng/dL) and eugonadal (testosterone >280 ng/dL) patients who required varicocelectomy. The mean testosterone level before surgery in hypogonadal patients was 215.22±83.31 ng/dL, which reached 326.95±35.125 ng/dL after surgery (P<0.0001), which was significant. There was no significant decrease in the mean FSH level, but there was a significant decrease in the mean LH level after varicocelectomy. In eugonadal group, testosterone level before surgery was 471.90±145.71 ng/dL, which reached 469.57±145.61 ng/dL after surgery, which was not significant.

Conclusion

In our study, patients who underwent varicocelectomy had improved testosterone levels, so that this increase was more significant in hypogonadal patients than in eugonadal patients. Decrease in LH and FSH levels in all patients was seen after varicocelectomy, which can be due to increase in testosterone levels.

Frontiers in hormone therapy for male infertility

For a significant number of couples worldwide, infertility is a harsh reality. As specialists in male infertility, much of our armamentarium lacks definitive, evidence-based therapies. For years, we have relied on manipulation of the male hormonal axis to treat those men who help carry the burden of infertility in their partnerships. Indeed, male factor infertility is the sole component of infertility in at least 20% of couples. Further compounding this dilemma is that 25% to 50% of males with infertility have no identifiable etiology and thus present a true management conundrum. This manuscript is an attempt to clarify what therapies exist for the treatment of male factor infertility. We have reviewed the relevant infertility literature honing, our focus on hormonal anomalies and their subsequent impact on fertility. Many of the therapies discussed have been utilized in practice for generations. Thus, this article attempts to provide the evidence-based literature to support the continued use of the current treatment paradigm. Furthermore, we recognize that any review beckons a discussion of what challenges and therapies await on the horizon. For instance, there has been significant interest in restoring spermatogenesis after testosterone replacement therapy (TRT). We explore the adverse long-term spermatogenic outcomes associated with TRT, which with the widespread use of TRT, will inevitably present a great challenge for male infertility specialists. Moreover, we discuss the role of varicocelectomy in the treatment of hypogonadism and infertility, review the association between growth hormone (GH) and male fertility and address the challenges presented by the rising prevalence of obesity.

Effects of Varicocelectomy on Serum Testosterone Levels among Infertile Men with Varicocele

Background

The main purpose of this study is to evaluate the effects of varicocelectomy on serum testosterone levels and semen quality in infertile men who suffer from varicocele.

MATERIALS AND METHODS

This prospective study enrolled 115 subjects with clinical varicocele grades II and III and 240 fertile men as the control group. Total volume of testosterone serum level (ng/dl) and semen quality were compared before and after microscopic varicocelectomy. We normalized testosterone serum levels for age, grade, and testis size basis. SPSS 20 software was used to analyze the data. All results of continuous variables were reported as mean ± SD. Statistical significance was set at a P<0.05.

RESULTS

The mean ages of individuals who participated in the treatment (32.2 ± 5.23) and control (32.8 ± 5.27) groups were similar. There were similar mean values for adjusted testosterone levels between the varicocele (567 ± 222 ng/ml) and control (583 ± 263 ng/ml) groups. In the varicocele group, the adjusted testosterone levels insignificantly increased to 594 ± 243 ng/ml. Among semen parameters, only mean sperm concentration significantly increased after varicocelectomy.

CONCLUSION

Despite increases in sperm concentration, adjusted testosterone levels did not significantly improve after varicocelectomy.

[Interventional treatment of benign prostatic hyperplasia : Embolization of the testicular vein]

CLINICAL/METHODICAL ISSUE

Embolization of the testicular veins (Gat-Goren technique) is an interventional procedure for the treatment of benign prostatic hyperplasia (BPH).

STANDARD RADIOLOGICAL METHODS

In addition to standard urological procedures, such as transurethral resection of the prostate (TUR-P), arterial embolization of the prostate is considered as the interventional radiological method of choice.

METHODICAL INNOVATIONS

Embolization of the testicular veins is technically identical to the embolization of varicoceles in infertile men and represents a less invasive treatment.

PERFORMANCE

Embolization of the testicular veins can be performed as a low-risk intervention with low side effects. Variants of the venous anatomy can make the procedure more difficult. In current studies a good reduction of symptoms could be achieved in intermediate-term follow-up.

ACHIEVEMENTS

The medium-term results are promising but data on long-term results and comparisons with alternative treatments are missing.

PRACTICAL RECOMMENDATIONS

Embolization of the testicular veins is a minimally invasive method for the treatment of BPH. The procedure can be performed in an outpatient setting. In the intermediate course up to 6 months after treatment, promising results were demonstrated in recent studies. Randomized studies, data on long-term results and comparisons to alternative methods (e. g. arterial prostatic embolization and surgical procedures) are missing.

The varicocele argument resurfaces

A recent series of articles and reviews published in Fertility and Sterility have rekindled the more than half century debate on varicocelectomy. Every one of these articles favored strongly the repair of varicocele for male infertility. Since my review paper on this issue in 2001, published in Human Reproduction Update, and since advent of ICSI in 1993, I had thought that most reproductive physicians felt negatively about the benefit of varicocelectomy. However, more recent urological papers are causing this negative view to be re-evaluated. It is now advocated by some urologists that varicocelectomy improves sperm count and testosterone levels, and even improves the results with ICSI. Thus, it may be appropriate to revisit older studies again and review the newer ones in this never ending controversy. Newer studies are re-opening the door to review and possibly re-instate varicocelectomy. This dilemma may never be fully resolved, but it is important to keep an open mind.

Varicocele management for infertility and pain: A systematic review

Despite being first described two thousand years ago, the varicocele remains a controversial multifaceted disease process with numerous biological consequences including infertility, hypogonadism, and chronic orchidalgia. The underlying mechanisms remain poorly understood and likely include hypoxia, oxidative stress, hyperthermia, anatomical aberrations, and genetics as primary components. Despite a high prevalence amongst asymptomatic fertile men, varicoceles paradoxically also represent the most common correctable cause for male infertility. In this systematic review we discuss the rich historical aspects of the varicocele and the contemporary data regarding its clinical manifestations. We performed a systematic literature review with the goal of comparing outcomes and complication rates of each of the major surgical approaches as they relate to infertility and pain. We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-compliant systematic literature review for manuscripts focused on varicocele and its biological consequences. We identified 112 studies suitable for qualitative analysis and included 56 of these for quantitative analysis, with an emphasis on infertility and chronic pain outcomes. Taken together, the clinical work to date suggests that the highest fertility rates and the lowest complication rates are associated with the microsurgical subinguinal surgical approach to varicocelectomy. In all, 26-40% of patients undergoing varicocelectomy will successfully achieve short-term spontaneous pregnancy, and up to 90% of all patients undergoing varicocelectomy for pain will have improvement and/or resolution of their symptoms. Taken together, the data support an ongoing role for varicocelectomy in both of these clinical arenas.

Significant alterations of 6-keto prostaglandin F1a and NO levels in spermatic vein plexus patients with varicocele

To investigate the level variation of correlative factors between the spermatic vein plexus and peripheral blood in patients with varicocele, a total of 22 patients diagnosed with varicocele were enrolled in the study. All patients were performed a testicular artery-sparing microsurgical varicocelectomy. During the operation, a blood sample from the left spermatic vein plexus and a peripheral blood sample were collected. A radioimmunoassay was used to determine the 6-keto prostaglandin F1a (6-keto-PGF1a ). A colorimetric method was performed to determine the NO. The enzyme immunoassay method was used to determine the creatinine, urea nitrogen, adrenaline, noradrenaline, dopamine and 5-HT. The mean age of all patients was 29.3 ± 7.8 years. Compared with the level of 6-keto-PGF1a and NO in the peripheral blood, 6-keto-PGF1a and NO were significantly increased in left spermatic vein plexus (347.3 (230.8-415.1) versus 99.7 (80.4-119.9) pg/ml and 192.3 ± 178.5 versus 107.1 ± 73.6 μmol/L, p < .05). There were no differences in the level of creatinine, urea nitrogen, adrenaline, noradrenaline, dopamine and 5-HT between the peripheral blood and left spermatic vein plexus (p > .05). The 6-keto-PGF1a and NO concentrations in left spermatic vein plexus were significantly higher than that in peripheral blood patients with varicocele.

Chrysin Administration Protects against Oxidative Damage in Varicocele-Induced Adult Rats

Oxidative stress is known as the leading factor responsible for varicocele-related infertility and for that reason, many antioxidant therapies have been proposed. Considering that, we evaluated the reproductive outcomes and fertility of varicocelized rats and the impact of chrysin within these parameters. The animals were allocated into three groups: sham (control), varicocele treated via gavage with 50 mg/kg/day of chrysin (V1), or vehicle (V2) for 56 days. Chrysin treatment prevented oxidative damage resulting from varicocele by decreasing testicular concentrations of malondialdehyde and sperm DNA fragmentation. It also improved histological aspect of the testis and maintained morphometric parameters similar to the sham group. Furthermore, there were no differences in body and reproductive organ weights, histopathological analysis of epididymis, sperm counts and morphology, testosterone levels, sexual behavior, and fertility parameters among experimental groups. Our results reinforce the idea that injuries provoked by experimental varicocele are related, at least in part, to oxidative stress. Moreover, varicocele showed bilateral deleterious effects without interfering with fertility. Chrysin administration significantly ameliorated sperm parameters, protecting the reproductive system against varicocele damages. For that reason, chrysin might be an alternative adjuvant therapy to improve sperm quality in men presenting this condition.

Should we expand the indications for varicocele treatment?

Current guidelines suggest that treatment of varicocele should be considered in patients with clinically palpable disease and abnormal semen parameters. However, the clinicians are often challenged with the decision whether to treat varicocele in patients with testicular pain or low testosterone levels. Moreover, varicocele is highly associated with DNA fragmentation due to the oxidative stress and it has been demonstrated that surgical repair of varicocele ameliorates oxidative stress markers and consequently the sperm DNA integrity. These new markers could have an adjunctive role to standard semen parameters especially when normal semen analysis is found in adult men with conventional methods. This review presents a contemporary overview of the rationale for varicocele treatment, as well as of the relationship between varicocele and other novel parameters such as DNA fragmentation index and reactive oxygen species. We will also discuss data from several recent series demonstrating that surgical treatment and especially microsurgical approach could resolve testicular pain, increase testosterone levels and fertility rate both in patients with non-obstructive azoospermia as well as in normozoospermia men. The correlation with progressive testicular failure will be also examined. We hope that this overview will provide clinicians with an evidence-based approach to managing these unanswered and conflicting topics.

Introduction: Varicoceles: a contemporary perspective

In this Views and Reviews section, four groups of authors address the timely and highly relevant issue of varicoceles across the male life spectrum. Varicoceles are very prevalent among men presenting for an infertility workup. While reduction in bulk semen parameters (including sperm concentration, motility, and morphology) has long been recognized as a deficit caused by varicoceles, in recent years a number of investigators have shown that varicoceles can have broader, multi-faceted effects on male reproductive health. Sperm DNA integrity and other aspects of sperm function appear to be impacted by the presence of varicoceles, and varicocele correction can result in significant improvement in not only semen parameters, but also fertilization and pregnancy rates.

Microsurgical Subinguinal Varicocele Repair of Grade II-III Lesions Associated with Improvements of Testosterone Levels

INTRODUCTION

The results of reports on the association between varicocele repair and testosterone levels were conflicting. The aim of the present study is, therefore, to investigate the impact of varicocele repair on testosterone levels.

MATERIALS AND METHODS

The study is based on 20 men who experienced microsurgical subinguinal varicoceles repair because of chronic dull scrotal pain. All hormonal profiles available in the clinical records were reviewed. Follow-up evaluation was done at 1 and 12 months after surgery. Men were classified into groups based on the preoperative testosterone levels: euogonadal (serum levels of testosterone > 12 nmol/l), hypogonadal men (serum levels of testosterone ≤ 12 nmol/l).

RESULTS

Microsurgical subinguinal varicocele repair was associated with a significant improvements of testosterone levels at 1 and 12 months after surgery as compared to the preoperative levels (13 nmol/l vs. 18 nmol/l, p = 0.03; 13 nmol/l vs. 15 nmol/l, p = 0.01). The same trend was seen in men who were classified as being hypogonadal (7.0 nmol/l vs. 15 nmol/l, p = 0.01; 7.0 nmol/l vs. 10 nmol/l, p = 0.02). No significant improvements in testosterone levels were observed in euogonadal men (p > 0.05).

CONCLUSION

Microsurgical subinguinal varicocele repair was associated with a significant improvements of testosterone levels in men with grade II-III lesions and low preoperative testosterone values.

Effects of varicocelectomy on serum testosterone

Varicocele is most often surgically repaired due to male infertility, however, has recently been linked to low serum testosterone. This paper serves to review the current literature regarding varicocele and its subsequent repair on serum testosterone. Twenty-eight human studies were identified with fifteen showing improved serum testosterone after repair. The majority of the studies that demonstrated improvement had preoperative testosterone levels that were low or below normal. Additionally, multiple well-designed studies with control groups not undergoing surgical repair demonstrated significant difference between groups. This improvement was less observed in studies with normal preoperative serum testosterone. A majority of these patients studied were presenting for infertility. It remains to be determined if these findings can be reproduced in men without infertility. The findings suggest that microsurgical varicocele repair can improve serum testosterone in men with low levels preoperatively in appropriately counseled men. It remains to be seen whether varicocele repair can help prevent the development of low testosterone in the future or which patients are at risk of developing low testosterone due to varicocele.

When is a varicocele repair indicated: the dilemma of hypogonadism and erectile dysfunction?

In the past, the indications for varicocelectomy are primarily for infertility with abnormal semen parameters, testicular hypotrophy/atrophy in adolescents, and/or pain. The surgical treatment of varicocele for hypogonadism is controversial and debated. Recently, multiple reports in the literature have suggested that varicocele is associated with hypogonadism and varicocele repair can increase testosterone levels. Men with hypogonadal symptoms should have at least two serum testosterone levels. Microsurgical varicocelectomy may be beneficial for men with clinically palpable varicoceles with documented hypogonadism. In this review, we summarize the most recent literature linking varicocele to hypogonadism and sexual dysfunction and the impact of repair on serum testosterone levels. We performed a search of the published English literature. The key words used were “varicocele and hypogonadism” and “varicocele surgery and testosterone.” We included published studies after 1998. We, also, evaluated the effect of surgery on the changes in the serum testosterone level regardless of the indication for the varicocele repair.

The Varicocele: Clinical Presentation, Evaluation, and Surgical Management

A varicocele is an abnormal dilatation and tortuosity of the veins of the spermatic cord. Although varicoceles are common in the general population and are frequently found on routine physical examinations, they represent the most common correctable cause of male factor infertility. Varicoceles are also often incidental findings on imaging studies, particularly scrotal ultrasound. Importantly, not all varicoceles should be treated equally (or at all), and basic guidelines on the evaluation and indications for treatment of adult varicoceles should be reviewed before counseling and treatment. A semen analysis should be obtained for any male patient of reproductive age considering intervention. The adolescent varicocele is managed much differently than the adult varicocele and remains a source of controversy. This review describes the clinical presentation and the evaluation of adult and pediatric varicoceles, and provides guidance on their diagnosis and workup. It also describes options for surgical repair and the success and complication rates associated with each surgical approach, ultimately supporting microsurgical subinguinal varicocele repair as the current surgical standard.

Varicocele - a case for early intervention

Testicular varicocele, which is defined as the dilation of the veins draining the testicle, has long been associated with a detrimental effect on testicular function. Despite a lack of high-quality, prospective data, recent evidence has shed light on potential links between varicocele and male infertility and serum testosterone levels. Similarly, varicocele repair has increasingly been shown to have a beneficial impact on pregnancy rates, semen parameters, and on improving serum testosterone in adult men. Numerous studies have assessed the optimal technique for varicocele repair and the bulk of the evidence has shown the microsurgical inguinal/subinguinal approach to have the highest success rates, the lowest overall complication rates, and the lowest recurrence rates. The management of varicocele in adolescents remains a clinical conundrum, but contemporary evidence suggests early deleterious effects of varicocele on testicular function in some patients. Well-designed prospective trials are critical to delineate the true impact and role of varicocele repair on male infertility and hypogonadism in adult and adolescent men.

Does the number of veins ligated during varicococele surgery influence post-operative semen and hormone results?

Varicocele is a well-established cause of male subfertility, which is directly proportional to its clinical grade. Although newer ultrasonic grading systems have taken into account the existence of pampiniform venous plexi, little is known about the clinical significance of the number of veins ligated during surgery. Very few undersized studies reported an influence which triggered the need to evaluate such association. This is a retrospective study of 378 patients who underwent left microsurgical subinguinal varicocoelectomy. Semen analyses and blood hormone studies performed pre-operatively were compared to those executed 6 months after surgery. Patients were divided into abnormal semen and normal semen groups based on their initial semen results. They were also subdivided according to the number of veins ligated intraoperatively into three groups: <5, 5-10, and >10 veins. Sperm count, total motility, and progressive motility were significantly increased in 62, 60.3, and 53.3% of patients post-operatively (p = 0.001), respectively. No significant differences in hormone levels were detected overall. Of the 378 patients, 332 had an abnormal semen analysis, while the remaining 46 patients had a normal result. Sperm count, total motility, and progressive motility significantly increased after varicocoelectomy in patients with an abnormal initial semen analysis (p = 0.001). In 48.7% of patients, 5-10 veins were ligated during surgery, whereas 28.3% had >10 and 23% had <5 ligated veins. No statistically significant differences were noted in the initial or the follow-up results among the number of vein subgroups. Varicocele ligation improves patients' fertility potential. This improvement, however, is not influenced by the number of veins ligated intraoperatively. Clinical grading maintains its superiority in the evaluation of varicocele patients.